Provider Demographics
NPI:1750069704
Name:PETRONE, DOMINIQUE (DMD)
Entity type:Individual
Prefix:
First Name:DOMINIQUE
Middle Name:
Last Name:PETRONE
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10280 SW STEPHANIE WAY UNIT 8201
Mailing Address - Street 2:
Mailing Address - City:PORT SAINT LUCIE
Mailing Address - State:FL
Mailing Address - Zip Code:34987-1962
Mailing Address - Country:US
Mailing Address - Phone:570-401-5478
Mailing Address - Fax:
Practice Address - Street 1:10670 SW TRADITION PKWY
Practice Address - Street 2:
Practice Address - City:PORT SAINT LUCIE
Practice Address - State:FL
Practice Address - Zip Code:34987-2862
Practice Address - Country:US
Practice Address - Phone:772-345-8332
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-07-10
Last Update Date:2023-07-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL28243122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist